November, 2016 - SUPPORT Summary of a systematic review | print this article |

What are the impacts of healthcare settings and organisation on the provision of care for those living with HIV-AIDS?1

There are substantial challenges to the provision of care for those living with HIV/AIDS. Several of the key issues involved relate to where care should be provided and how it should be organized.

 

Key messages

Setting of care:

 

  • Units dedicated to AIDS care and high volume institutions may reduce mortality among people living with HIV/AIDS.
  • High volume institutions probably reduce the number of emergency department visits and the length of hospital stays among people living with HIV/AIDS.
  • The effects of other interventions related to the setting of care, such as outreach or in-terventions to reduce travel time to providers, are uncertain.

Organisation of care:

 

  •  Case management may reduce mortality and the number of emergency department visits among people living with HIV/AIDS. Other effects of case management are un certain.
  • Computer prompts probably hasten initiation of recommended treatments for patients with HIV/AIDS. Other effects of computer prompts and information systems are uncer-tain.
  • The effects of multidisciplinary or multifaceted interventions are uncertain.

All the studies reviewed were conducted in high-income coun-tries.

 

 

Background

The high burden of HIV/AIDS has placed greater demands on healthcare institutions and can present organisational challenges. Key health system issues include whether such care should be centralised or decentralised, the preferred type and mix of health workers, and which interventions and mix of programmes would best facilitate delivery of care. High volume centres (seeing high volume of patients), case management, and multidisciplinary care have been shown to be effective strategies for other chronic illnesses. However, whether these findings can be applied to the context of HIV/AIDS healthcare is less well understood.


About the systematic review underlying this summary

Review objectives: To determine the effects of the setting of care and the organisation of care on medical,immunological/virological, psychosocial and/or economic outcomes for persons living with HIV/AIDS
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, non-randomised trials, cohort studies, case control studies, cross-sectional studies, and controlled before-after studies that evaluated the settings and organisation of care 1 randomised trial, 1 non-randomised trial, 5 prospective cohort studies, and 21 retrospective cohort studies were included. 
Participants Persons (men, women and children) known to be infected with HIV/AIDS 39,776 HIV-positive participants were included
Settings All settings Clinical trial settings; hospitals and clinics in high-income country settings
Outcomes Medical outcomes, immunological or virological outcomes, psychosocial outcomes, economic outcomes Mortality (12 studies), receipt of antiretrovirals or indicated prophylaxis as an outcome (10 studies), hospitalisation (5 studies), functional status (1 study), healthcare utilisation outcomes (16 studies)
Date of most recent search: December 2002
Limitations: This is a well conducted systematic review with only minor limitations. However, it has not been updated since the last search in December 2002.

To determine the effects of the setting of care and the organisation of care on medical, immunological/virological, psychosocial and/or economic outcomes for persons living with HIV/AIDS

Handford C, Tynan AM, Rackal JM, Glazier R. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database of Systematic Re-views 2006, Issue 3. Art.No.: CD004348.

Summary of findings

Twenty-eight studies, all conducted in high-income countries, evaluating the setting and organisation of care were included. Interventions included the concentration of HIV/AIDS patients (1 study); clinic, hospital or hospital ward volumes (13); the conducting of clinical trials (4), the incorporation of trainees (3), and hours of service (3). Case management interventions were described in 3 studies, multidisciplinary or multi faceted treatment interventions in 6 studies, and health information systems in three. No studies evaluated outreach or travel time to providers as an intervention.

1) Setting of care

Among people living with HIV/AIDS:

 

  • Units dedicated to AIDS care and high volume institutions may reduce mortality. The certainty of this evidence is low.
  • High volume institutions probably reduce the number of emergency department visits and the length of hospital stays. The certainty of this evidence is moderate.
  • Units that participate in clinical trials may increase the pro-portion of patients taking antiretroviral drugs. The certainty of this evidence is low.
  • No studies were found that evaluated outreach or interventions to reduce travel time to providers as an intervention. We are therefore uncertain of the effects of outreach or travel time on the provision of care for people with HIV/AIDS.

High volume institutions

People:  People with HIV/AIDS
Intervention
: High volume institutions
Comparison
: Lower volume institutions
Outcomes Impact Certainty of the evidence
(GRADE)
30-day mortality Five studies reported reduced 30-day mortality in high volume institutions compared to lower volume institutions; 4 other studies were inconclusive. 

Low

Length of hospital stays
Two studies demonstrated longer hospital stays in facilities with higher HIV-volumes compared to low volume facilities and reported differences of 5.0 and 2.7 days respectively. Three studies reported differences of 2.0 days or less when comparing high volume with low volume facilities.

Low

Healthcare utilisation  One study found fewer emergency department visits (ED) (31 vs. 43 visits, p=0.01) for patients randomised to a high-volume HIV infectious diseases practice (1,100 HIV-infected patients) compared to a low-volume general medicine practice (<50 HIV‑infected patients). There was no difference reported between the groups in terms of the number of patient visits to the home clinic. Another study found that higher-volume institutions had fewer patients with 2 or more ED visits (aOR 0.56, CI 0.44 to 0.71) compared to patients from lower-volume institutions.

Moderate

P: p-value; aOR: adjusted odds ratio; CI: confidence interval; GRADE: GRADE Working Group grades of evidence (see above and last page)

 

2) Organisation of care

Among people living with HIV/AIDS: 

  • Case management may reduce mortality and the number of emergency department visits. The certainty of this evidence is low. Other effects of case man-agement are uncertain.
  • Computer prompts probably hastened initiation of recommended treatments for patients with HIV/AIDS. The certainty of this evidence is moderate. Other effects of computer prompts and information systems are uncertain.
  • The effects of multidisciplinary or multifaceted interventions are uncertain.

 

Case management

People:  People with HIV/AIDS
Intervention
: Case management
Comparison
: No case management
Outcomes Impact Certainty of the evidence
(GRADE)
30-day mortality Improved two-year survival period (86% vs. 64%, p<.001) for patients who were actively involved in an Early Intervention Program which included case management as compared to patients who were not actively involved in the Program. 

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
None of the studies in this review were conducted in low-income countries.   It may be difficult for policymakers to replicate the study settings or organisation of care in low income countries.
EQUITY
The included studies provided little data regarding the differential effects of the interventions on disadvantaged groups within the included populations. The effects of changes in the setting or organisation of care may vary in disadvantaged communities.
ECONOMIC CONSIDERATIONS
Economic evaluations were not reported on in the review. Changes to the organisation of care may require training, human resources, the provision of necessary drugs and supplies, and have other associated costs. The cost-effectiveness and sustainability of such measures are uncertain.
MONITORING & EVALUATION
Some interventions included in this review appeared promising, but the certainty of the evidence was mostly low or very low.

Consideration should be given to evaluating the impact of the interventions described using robust methods before attempts are made to implement large‑scale changes. Both intended outcomes and potential adverse effects should be evaluated and monitored.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm

 

Additional information

Related literature

Ofman JJ, Badamgarav E, Henning JM, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. American Journal of Medicine 2004; 117:182–92.

 

Oxman AD, Bjorndal A, Flottorp S, Lewin S, Lindahl AK: Integrated Health Care for People with Chronic Condi-tions. Oslo, Norwegian Knowledge Centre for the Health Services; 2008. http://www.kunnskapssenteret.no/en/publications/integrated-health-care-for-people-with-chronic-conditions.a-policy-brief

 

Bemelmans M, Van Den Akker T, Ford N, et al. Providing universal access to antiretroviral therapy in Thyolo, Ma-lawi through task shifting and decentralization of HIV/AIDS care. Trop Med Int Health 2010; 15(12):1413-20.

 

This summary was prepared by

Taryn Young, South African Cochrane Centre, South African Medical Research Council, Cape Town, South Africa

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Edward Mills, Anne-Marie Tynan, Simon Goudie, and Hanna

Bergman.

 

This review should be cited as

Handford C, Tynan AM, Rackal JM, Glazier R. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database of Systematic Reviews 2006, Issue 3. Art.No.: CD004348.

 

The summary should be cited as

Young T. What are the impacts of healthcare settings and organisation on the provisions of care for those living with HIV/AIDS? A SUPPORT Summary of a sys-tematic review. November 2016. www.supportsummaries.org

 

Keywords

 

evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, organisation of care, setting of care, HIV/AIDS

 

This summary was prepared with additional support from:

 

The South African Medical Research Council aims to improve South Africa’s health and quality of life through promoting and conducting rele-vant and responsive health research. www.mrc.ac.za/

 

 

Cochrane South Africa, the only centre of the global, independent Cochrane network in Africa, aims to ensure that health care decision mak-ing within Africa is informed by high-quality, timely and relevant research evidence. www.mrc.ac.za/cochrane/cochrane.htm

 

 



Comments